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David Fletcher, MD Department of Medicine University of Toronto

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Complicated cases. David Fletcher, MD Department of Medicine University of Toronto. CASE 1 . 54 yr /o man HIV positive 8 yrs ago Tenofovir /FTC/RTV/ Atazanavir x 4 yrs Previously documented NNRTI resistance with Y181C, G190A,and mixed m184v/ wt CD4 320 HIV Viral Load<40. CASE 1 .

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Complicated cases

David Fletcher, MDDepartment of MedicineUniversity of Toronto

case 1
CASE 1
  • 54 yr/o man
  • HIV positive 8 yrs ago
    • Tenofovir/FTC/RTV/Atazanavirx 4 yrs
    • Previously documented NNRTI resistance with Y181C, G190A,and mixed m184v/wt
    • CD4 320 HIV Viral Load<40
case 11
CASE 1
  • Genotype 1a Hepatitis C biopsy proven cirrhosis
  • Compensated and clinically stable
    • Previous therapy in 2009 with Peg INF/1200mg RBV daily resulted in a null response by history from the patient
case 12
CASE 1

Patient is interested in a retrial of therapy for Hepatitis C with the new direct acting antiviral agents

  • Would you offer treatment?
  • Chance of cure?
  • Which 3rd agent would you choose and why?
  • Does patient’s antiretroviral history play a role in 3rd agent choice?
  • Is there a role for a 4 week lead in here regardless of agent chosen and if so…why?
case 13
CASE 1

It was decided to move forwards with Peg INF/ 1200mg RBV/Telaprevir

  • Is it necessary to change current ARVs?
  • Would it be necessary to change ARVs if Boceprevir was chosen?...to what?
case 14
CASE 1

Peg INF/1200mg RBV/Telaprevir…no lead in performed

  • Week 0 HCVRNA 3.7 x 10e7
  • Week 4 HCVRNA detectable but<12
  • Would you continue?
  • Are you concerned about the result?
  • When would you do the next HCVRNA?
case 15
CASE1

It was decided to continue with Peg INF/1200mg RBV/Telaprevir and HCVRNA rechecked

  • Week 0 HCVRNA 3.7 x 10e7
  • Week 4 HCVRNA detectable but<12
  • Week 6 HCVRNA <12
  • Would you continue?
case 16
CASE 1

Peg INF/1200mg RBV/Telaprevir

  • Week 0 HB 140
  • Week 2 HB 125
  • Week 4 HB 109
  • Week 6 HB 99…symptomatic
  • How would you manage anemia?
case 17
CASE 1

Peg INF/600mgRBV/Telaprevir

  • Week 0 HCVRNA 3.7 x 10e7
  • Week 4 HCVRNA detectable but<12
  • Week 6 HCVRNA <12 HB 99 (symptoms)
  • Week 8 HCVRNA <12 HB 98 (less symptomatic)
  • What would you do?
  • How would you further manage anemia
case 18
CASE 1

Peg INF/600mg RBV/Telaprevir

  • Week 0 HCVRNA 3.7 x 10e7
  • Week 4 HCVRNA detectable but<12
  • Week 6 HCVRNA <12
  • Week 8 HCVRNA <12
  • Week 12 HCVRNA detectable but <12 HB 103
  • What would you do?
  • When would you do your next HCVRNA?
case 19
CASE 1

Peg INF/RBV re-increased to 1200mg

  • Week 0 HCVRNA 3.7 x 10e7
  • Week 4 HCVRNA detectable but <12
  • Week 8 HCVRNA <12
  • Week 12 HCVRNA detectable but <12
  • Week 14 HCVRNA <12 HB 101
  • What would you do?
case 110
CASE 1

Peg INF/1200mg RBV

  • Week 0 HCVRNA 3.7 x 10e7
  • Week 4 HCVRNA detectable but<12
  • Week 12 HCVRNA detectable but <12
  • Week 14 HCVRNA <12 HB 101
  • Week 24 HCVRNA <12 HB 105
  • How much longer would you treat?
  • When would you do your next HCVRNA?
case 111
CASE 1

Peg INF/1200mg RBV

  • Week 0 HCVRNA 3.7 x 10e7
  • Week 4 HCVRNA detectable but <12
  • Week 12 HCVRNA detectable but <12
  • Week 24 HCVRNA <12
  • Week 36 HCVRNA <12
  • Week 48 HCVRNA <12
  • Are we finished therapy?
case 112
CASE 1

An additional 24 weeks of PEG INF/RBV (for a total of 72 weeks of therapy) was offered to the patient given the existence of cirrhosis and ?slow HCVRNA clearance as evidenced by a detectable HCVRNA at week 4 and 12

Week 12 and 24 HCVRNA post 72 weeks of therapy were undetectable!

case 2
CASE 2
  • 52 yo man
  • HIV positive 5 yrs ago
    • CAD with previous MI 3 yrs ago/Hypertensive/Hypothyroidism
  • Tenofovir/FTC/Raltegravir x 4 yrs
    • CD4 700 HIV Viral Load<40
case 21
CASE 2
  • Hypercholesterolemia and Hypertriglyceridemia on combination therapy with Atorvastatin 80mg/day and Fenofibrate 145mg/day
  • Hypertension controlled on Amlodipine 10mg/day
  • Hypothyroidism controlled on 0.125 mg L-Thyroxine
case 22
CASE 2
  • Genotype 1a chronic hepatitis C
  • Naïve to therapy
  • F2-3/4 scarring
  • Ready to start triple therapy with PEG INF/RBV/Boceprevir
  • Atorvastatin decreased to 40mg/day
  • Baseline HCVRNA 1.66X10E6
case 23
CASE 2
  • Week 0 HCVRNA 1.66x10E6
  • Week 4 HCVRNA (lead in)2.37x 10E2
  • Week 8 HCVRNA <12
  • At week 10 begins to feel tired/weak/constipated/muscle cramping
  • TSH noted to be 18.91…L-T4 increased to 0.15mg/d in response
case 24
CASE 2
  • At week 11 notes increasingly prominent myalgias, more predominant post interferon injection but lasting all week long as opposed to a few hrs post injection, along with increasing weakness
  • Hb stable at 105g/l over last few weeks with RBV dose reduction to 600mg/d
  • AST noted to be increasing while ALT has been normalizing over the last few weeks…also increasing swelling of ankles
    • ?Cause…Hepatic Decompensation?
case 25
CASE 2
  • CK measured at 83,700
  • BP noted to be low at 90/55 and swelling of ankles worsened now to mid calf…no ascites noted clinically
  • Cause?
case 26
CASE 2
  • Atorvastatin and Fenofibrate discontinued!!!
  • CK fell over the next few weeks as did AST
  • The symptomatic myalgias and weakness improved over the subsequent month
  • Amlodipine discontinued…BP normalized to 130/80 and ankle swelling disappeared over the next month
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